INTRODUCTION — Obesity is a risk factor for cesarean birth, and the risks and challenges of cesarean birth increase with increasing severity of obesity. Perioperative planning and appropriate intervention help to reduce these risks and ensure optimal maternal and newborn outcomes.
The Enhanced Recovery After Surgery (ERAS) Society has published guidelines for perioperative care of patients undergoing cesarean birth, the ERAS Cesarean Delivery Guidelines, which cover the time from decision to operate (starting with the 30 to 60 minutes before skin incision) to hospital discharge [1-3]. The American College of Obstetricians and Gynecologists (ACOG) has published a guideline for enhanced recovery after surgery [4]. Other organizations and many hospitals have also created such guidelines/pathways [5]. However, no specific guideline exists for perioperative care of patients with obesity undergoing cesarean birth.
This topic will present an overview of issues relating to cesarean birth of the patient with obesity. Many of these issues are the same as those for the overall obstetric population and are discussed in detail separately:
●(See "Cesarean birth: Preoperative planning and patient preparation".)
●(See "Cesarean birth: Surgical technique".)
●(See "Cesarean birth: Postoperative care, complications, and long-term sequelae".)
●(See "Anesthesia for cesarean delivery".)
The numerous maternal and perinatal risks of obesity during pregnancy and the immediate postpartum period and the anesthetic and surgical issues in individuals with obesity are also reviewed separately:
●(See "Obesity in pregnancy: Complications and maternal management".)
●(See "Anesthesia for the patient with obesity".)
FACTORS TO CONSIDER DURING SURGICAL PLANNING — The following factors should be considered in patients with obesity undergoing cesarean birth. The relative contribution of each factor to the risk of an adverse outcome, such as wound infection/disruption, endometritis, or thromboembolism, compared with patients without obesity has not been clearly defined [6-14].
●Baseline health hazards – Obesity is associated with numerous health hazards (table 1). (See "Overweight and obesity in adults: Health consequences".)
●Perioperative respiratory dysfunction – Obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS) are the most important respiratory problems associated with obesity (see "Obstructive sleep apnea in pregnancy"). However, patients with obesity without these disorders are still at risk of perioperative respiratory dysfunction due to functional and mechanical changes related to obesity. (See "Preanesthesia medical evaluation of the patient with obesity" and "Anesthesia for the patient with obesity".)
●Type of cesarean birth – Obesity increases the chances of both scheduled and emergency cesarean birth. Emergency cesareans are associated with higher risks for intraoperative and postoperative complications than scheduled procedures [15,16]. (See "Obesity in pregnancy: Complications and maternal management", section on 'Cesarean birth'.)
●Need for specialized equipment – Surgery in patients with obesity often requires specialized equipment (eg, high-weight-capacity operating tables, bariatric width extenders, lifts, long instruments, large blood pressure cuffs, large pneumatic compression devices). (See "Hospital accreditation, accommodations, and staffing for care of the bariatric surgical patient", section on 'Facilities/equipment/instruments'.)
●Difficulty placing intravenous lines – Peripheral intravenous (IV) lines may be difficult to place due to subcutaneous adiposity. Central venous access may be needed if peripheral access is tenuous, but central venous access may also be difficult. Ultrasound guidance can be used for placing central and peripheral venous catheters. (See "Principles of ultrasound-guided venous access".)
●Difficulty placing neuraxial anesthesia – Placement of neuraxial needles and catheters can be challenging because the usual anatomic landmarks are not easily palpable, the patient may be unable to flex their back adequately, and the distance from skin to target is longer than in patients without obesity. Ultrasound guidance may be helpful. Although the rate of successful neuraxial anesthesia is similar for pregnant patients with severe obesity and those without obesity, it is more likely that placement will require additional attempts and need for repeated placement due to epidural failure [17,18]. (See "Anesthesia for the patient with obesity", section on 'Neuraxial anesthesia'.)
●Difficulty with ventilation – It is more likely that mask ventilation may be difficult and intubation may be difficult or may fail. (See "Anesthesia for the patient with obesity", section on 'Difficulty with airway management'.)
●Longer operative time – Incision-to-delivery time and total operative time are longer on average.
●Increased blood loss – Mean blood loss is increased, but blood transfusion is not clearly more frequent.
●Altered pharmacodynamics – Pharmacodynamics may be altered because patients with obesity have a larger blood volume and volume of distribution for lipophilic drugs, and a decrease in lean body mass and tissue water, compared with controls without obesity. These changes predispose patients with obesity to both subtherapeutic and toxic responses to medications. (See "Anesthesia for the patient with obesity", section on 'Dosing anesthetic drugs'.)
PREOPERATIVE EVALUATION AND TESTING
●Anesthesia consultation – Ideally, patients with class II or III obesity are scheduled for an antepartum consultation with the anesthesia team, given the multiple anesthetic and surgical risk factors discussed above. (See 'Factors to consider during surgical planning' above.)
Scheduling the consultation in the early to mid-third trimester is prudent in case of late preterm or early term birth. Preoperative history, physical examination, and selective testing can identify patients with comorbidities, such as a potentially difficult airway or obstructive sleep apnea (OSA), that increase their risk of complications during and following surgery. Preanesthetic evaluation and other issues related to anesthesia and postoperative care of patients with obesity are discussed in detail separately. (See "Preanesthesia medical evaluation of the patient with obesity".)
●Blood bank – A type and screen is generally considered adequate for patients with obesity and no other high-risk factors for postpartum hemorrhage. The Joint Commission recommends that hospitals use an evidence-based assessment tool for determining the risk of hemorrhage in all obstetric patients upon admission to the labor and delivery and postpartum units, and counsel/manage patients based on their level of risk [19]. The decision to type and screen versus crossmatch is based on the clinician's assessment of level of risk. Several tools have been created for risk assessment, but none are predictive of severe hemorrhage, particularly in the absence of an obvious high-risk factor (eg, placenta accreta spectrum, placenta previa, low-lying placenta, placental abruption, coagulopathy, severe anemia) or at least two moderate risk factors (eg, prior cesarean birth/uterine surgery, multiple gestation, large fibroids, prior postpartum hemorrhage) [20,21]. Risk assessment and planning is reviewed separately. (See "Overview of postpartum hemorrhage", section on 'PPH risk assessment tools and risk-based preparation'.)
●Electrocardiogram – The decision to obtain an ECG should be individualized, taking into account the following factors. The American Heart Association (AHA) 2009 scientific advisory on cardiovascular evaluation and management of patients with body mass index (BMI) ≥40 kg/m2 undergoing surgery states that a 12-lead ECG is reasonable in those with at least one risk factor for perioperative cardiovascular morbidity (coronary heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes mellitus, chronic renal insufficiency with creatinine level >2.0 mg/dL) or poor exercise tolerance [22]. However, cardiac changes (ventricular hypertrophy, systolic and/or diastolic dysfunction, atrial fibrillation) can occur in the absence of these risk factors in patients with longstanding severe obesity, so these factors should be considered as well [23,24]. (See "Preoperative medical evaluation of the healthy adult patient", section on 'Electrocardiogram' and "Obesity in adults: Prevalence, screening, and evaluation", section on 'Assessing obesity-related health risk' and "Obesity in pregnancy: Complications and maternal management", section on 'Baseline assessments and referrals'.)
●Perioperative respiratory function – Preoperative identification of OSA helps in planning interventions to reduce respiratory morbidity, which can be aggravated by immobility, positioning, pain, and use of opioids. Clinical questionnaires or prediction scores (eg, STOP-Bang, Berlin) can be used for screening but are less reliably predictive in pregnant people. Patients with obesity who report snoring, witnessed apnea, or drowsiness episodes should be referred for evaluation by a sleep medicine specialist and possible polysomnography. Screening, evaluation, and treatment of OSA in pregnancy are reviewed in detail separately. (See "Obstructive sleep apnea in pregnancy".)
PREOPERATIVE INTERVENTIONS TO REDUCE THE RISK OF COMPLICATIONS — In a large retrospective study of patients undergoing primary and repeat cesarean births, the rate of intraoperative complications was low (3 to 4 percent of cases) and not significantly increased in patients with obesity, suggesting that surgical preparedness and appropriate conduct of surgery can decrease complication rates [16]. These measures are discussed in the following subsections and below. (See 'Operative procedure' below.)
Prevention of aspiration — Both pregnancy and elevated BMI are consistently associated with higher rates of gastroesophageal reflux. Measures to reduce the risk of aspiration (eg, fasting before scheduled cases and avoidance of solid food in labor; administration of nonparticulate antacids, H2-receptor antagonists and/or metoclopramide) are similar to those in pregnant patients without obesity. (See "Anesthesia for cesarean delivery", section on 'Preparation for anesthesia'.)
Prevention of venous thromboembolism — We suggest application of an intermittent pneumatic compression device sized to accommodate large legs preoperatively, and the addition of pharmacologic thromboprophylaxis postpartum once the patient is deemed stable from a surgical/anesthesia standpoint.
Thromboprophylaxis is typically recommended for patients with obesity undergoing cesarean birth, given that pregnancy, cesarean birth, and obesity are all risk factors for postpartum venous thromboembolism (VTE). Virtually all pregnant people undergoing cesarean birth in the United States receive mechanical prophylaxis. Although details among medical society guidelines vary, both mechanical and pharmacologic thromboprophylaxis are recommended for patients at higher risk of VTE, such as those with obesity. Choice of drug (unfractionated versus low molecular weight heparin), timing of administration, dosing, and duration of thromboprophylaxis (during hospitalization only versus for six weeks) are reviewed separately. (See "Cesarean birth: Preoperative planning and patient preparation", section on 'Thromboembolism prophylaxis'.)
Prevention of surgical-site infection — Important components of infection prophylaxis include using aseptic practices, minimizing duration of surgery, weight-based antibiotic prophylaxis, and preoperative optimum glycemic management in patients with diabetes [25]. Selected specific measures in patients with obesity undergoing cesarean birth are discussed below. (See 'Preparation of the abdomen and vagina' below and 'Antibiotic prophylaxis' below.)
A general discussion of standard measures to prevent surgical site infections (SSIs) can be found separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Overview of control measures for prevention of surgical site infection in adults".)
Preparation of the abdomen and vagina — Both the abdomen and vagina are prepped with an antiseptic solution, as in patients without obesity. The choice and efficacy of agents for skin and vaginal preparation are reviewed separately. (See "Cesarean birth: Preoperative planning and patient preparation", section on 'Skin preparation' and "Cesarean birth: Preoperative planning and patient preparation", section on 'Vaginal preparation'.)
Antibiotic prophylaxis
●Patients without penicillin allergy – For patients with obesity undergoing cesarean birth at average risk of infection, dosing is based on weight as follows [26]:
•≥120 kg: cefazolin 3 g intravenously (IV) within the 60 minutes prior to surgical incision
•<120 kg: cefazolin 2 g IV within the 60 minutes prior to surgical incision
For patients in labor and/or with rupture of membranes: add azithromycin 500 mg IV [27].
For patients with ruptured membranes who undergo cesarean birth without preoperative IV azithromycin, administering cefazolin 2 or 3 g IV preoperatively followed by cephalexin 500 mg orally plus metronidazole 500 mg orally every 8 hours for 48 hours following cesarean birth is another approach to reducing SSI [28].
●Patients with penicillin allergy – For patients with a true penicillin allergy (immediate hypersensitivity reaction), combination therapy with clindamycin 900 mg plus gentamicin 5 mg/kg (dosing weight) intravenously provides broad coverage [29]. Gentamicin dosing is calculated based on the patient's dosing weight. For patients whose weight is 1 to 1.25 times their ideal body weight (IBW), we typically use IBW to calculate dose. For patients with obesity whose weight is >1.25 times their IBW, we use the adjusted body weight (AdjBW) as follows: AdjBW, in kg = IBW + [0.4 x (TBW - IBW)].
IBW can be estimated by the calculator (calculator 1) and following formula: IBW, in kg (females) = 45.5 + (2.3 x inches above 60 inches). (See "Dosing and administration of parenteral aminoglycosides", section on 'Dosing weight'.)
Evidence — The value of preincision antibiotic prophylaxis for cesarean birth has been consistently demonstrated in meta-analyses of randomized trials (see "Cesarean birth: Preoperative planning and patient preparation", section on 'Antibiotic prophylaxis'). However, evidence for optimum dosing in the population of patients with obesity is limited.
●Higher dosing – Standard doses of antimicrobial agents, particularly the cephalosporins [30,31], result in low serum and tissue levels in patients with obesity (≥20 percent of patients with obesity did not achieve minimal inhibitory concentrations for Gram-negative rods in incisional adipose samples with a 2 g dose in one study [30]); therefore, higher doses of the prophylactic antimicrobial agent should be administered [32].
In 2013, guidelines developed jointly by the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA) recommended cefazolin 3 g for patients ≥120 kg undergoing cesarean birth and 2 g for patients <120 kg [26,29]. They also suggest consideration of additional intraoperative doses in patients with excessive blood loss or extended surgery (duration exceeding two half-lives of the drug), which is the standard of care in other surgeries. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
By comparison, the American College of Obstetricians and Gynecologists (ACOG) recommends a single dose of a first-generation cephalosporin, but dosing is different (cefazolin 1 g IV for patients <80 kg, 2 to 3 g IV for patients ≥80 kg) [33].
●Extended-spectrum dosing – Emerging data support use of extended-spectrum antibiotic combinations for patients at high risk of postcesarean infection (eg, cesareans performed intrapartum or after rupture of membranes). In a randomized trial of over 1000 patients undergoing unplanned cesarean after receiving cefazolin with versus without IV azithromycin prophylaxis, the adjunctive azithromycin group had a significant reduction in the primary composite outcome of endometritis, wound infection, or other infections (relative risk [RR] 0.51, 95% CI 0.38-0.68), with no significant difference in the neonatal composite outcome, including death and serious complications [34]. A meta-analysis of this trial and others that included both scheduled and unplanned cesareans reported a similar reduction in infection (SSI: 6.3 versus 13.6 percent; RR 0.46, 95% CI 0.34-0.63) [27]. (See "Cesarean birth: Preoperative planning and patient preparation", section on 'Regimen'.)
●Postpartum antibiotics – Traditionally, prophylaxis has not been continued postpartum because studies in general surgical populations showed no benefit from postoperative antimicrobial prophylaxis [29]. However, a randomized trial in over 400 patients with obesity (BMI ≥30 kg/m2) that compared oral cephalexin 500 mg plus metronidazole 500 mg versus placebo every 8 hours for 48 hours following cesarean birth (in addition to 2 g IV preoperative cefazolin prophylaxis) reported a reduction in SSIs (6.4 versus 15.4 percent, RR 0.41, 95% CI 0.22-0.77; number needed to treat to prevent one SSI: 12) [28].
Post hoc analysis showed that, when comparing the same regimen with placebo, the 126 patients with membrane rupture prior to cesarean had a significant reduction in SSI (mean difference 20.6 percent, 95% CI 6.9-34.3 percent) that was not demonstrated in the 277 patients without membrane rupture (difference 3.7 percent, 95% CI -2.3 to 9.6 percent). The frequency of SSI in the control group was quite high and the dose of IV cefazolin was lower than our recommendation for 3 g in patients ≥120 kg, thus the results may not be generalizable to hospitals/patients with obesity with lower SSI rates and patients with obesity who receive a higher dose of IV cefazolin. It is also unclear if the benefits of postoperative oral antibiotics would exceed that of administration of IV azithromycin at the time of the cesarean birth. However, in patients with obesity and ruptured membranes not receiving preoperative IV azithromycin, this postoperative oral regimen may be considered [35].
ANESTHESIA — Challenges and complications related to anesthesia are more common in patients with obesity, and include difficulty with monitoring, positioning, airway management, and neuraxial techniques, as well as longer surgical duration and increased risk of aspiration of gastric contents [17].
The choice between general and regional anesthesia should be guided by the urgency of the case, requirements of the surgical procedure, and comorbidities. Although patient preferences are also important, regional anesthesia is recommended for this patient population, especially those with severe obesity, because it is safer than general anesthesia [36,37]. For patients planning vaginal birth, early placement of a neuraxial catheter during labor may obviate the need for general anesthesia in case of emergency cesarean birth.
Anesthesia issues of patients with obesity are reviewed in detail separately:
●(See "Anesthesia for the patient with obesity".)
●(See "Anesthesia for cesarean delivery".)
●(See "Airway management for the pregnant patient".)
OPERATIVE PROCEDURE
Logistics
●Preoperative fetal heart rate monitoring – Fetal heart rate (FHR) monitoring before the start of surgery can usually be achieved with a traditional Doppler FHR monitor.
●Choice of operating table – Special operating tables may be needed. For example, a standard operating table has a weight capacity up to 500 pounds (227 kg), while a bariatric surgical table has a weight capacity up to 1000 pounds (454 kg). Bariatric table width extenders can be useful in increasing the support surface of the operating table. (See "Hospital accreditation, accommodations, and staffing for care of the bariatric surgical patient", section on 'Operating rooms'.)
●Transferring the patient to the operating table – Moving and positioning the patient with obesity can be difficult and must be done carefully to prevent falls and other uncontrolled movements, as well as injury to the patient and staff. A hydraulic or ceiling lift or an air transfer system (eg, HoverMatt) can be useful to lift and move the patient, and helps to prevent patient and staff injury. (See "Hospital accreditation, accommodations, and staffing for care of the bariatric surgical patient", section on 'Patient lifts'.)
●Patient positioning – Patient positioning is important to limit unfavorable physiological sequelae (eg, supine hypotension, respiratory dysfunction), provide optimum exposure for surgical procedures, and reduce the risk of perioperative nerve, joint, and soft tissue injury. Pressure points (including buttocks, lumbar region, and shoulders) should be well-padded to prevent skeletal muscle necrosis [38].
Patients should be positioned with left uterine displacement to minimize the chance of aortocaval compression and supine hypotension. Traditionally, 15 degrees of lateral displacement is recommended. (See "Anesthesia for cesarean delivery", section on 'Intraoperative positioning'.)
●Blood pressure monitoring – Blood pressure must be monitored with an appropriately sized blood pressure cuff. A thigh cuff is advised if the arm circumference is 45 to 52 cm and a large adult cuff if arm circumference is 35 to 44 cm (see "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Cuff size'). If external measurements are not reliable, which sometimes happens in these cases, blood pressure can be monitored invasively.
●Intermittent pneumatic compression devices – Intermittent pneumatic compression devices sized to accommodate large legs are applied preoperatively. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Intermittent pneumatic compression and venous foot pump'.)
●Surgical exposure – A removable adhesive panniculus retractor/retention system or surgical tape placed prior to start of the cesarean for rostral retraction may improve exposure without concern for pressure points that may be caused by manual retraction (as described in a case report of pressure necrosis of the panniculus from prolonged digital retraction [39]). A self-retaining intraabdominal retractor can be added for the intraabdominal procedures. In our experience, self-retaining retractors have not impeded fetal delivery, but this is a theoretic concern.
The panniculus retractor/retention system may be left in place postoperatively to assist in keeping the incision clean and dry. The clinician should be familiar with the manufacturer's instructions for duration of use for the device/system as these can vary.
Of note, retracting an extremely large panniculus onto the thorax has been associated with cardiopulmonary compromise (eg, hypotension, hypoxia).
●Instruments and other supplies – Long instruments and wide deep retractors (including panniculus retractors) are usually required to access structures deep in the pelvis. Appropriately sized gowns and stretchers and monitoring equipment must be available for patients with obesity. (See "Hospital accreditation, accommodations, and staffing for care of the bariatric surgical patient", section on 'Operating rooms' and "Hospital accreditation, accommodations, and staffing for care of the bariatric surgical patient", section on 'Other supplies' and "Hospital accreditation, accommodations, and staffing for care of the bariatric surgical patient", section on 'Monitoring and safety devices'.)
Abdominal wall incision — The patient's body habitus, including weight distribution and panniculus size, need to be carefully assessed before deciding upon the appropriate incision. The type of incision may affect exposure, ease of fetal extraction, postoperative pain and respiratory effort, wound strength, and wound complication rates.
●Landmarks – The surgeon must be aware of how abdominal wall adipose tissue can affect typical anatomic landmarks. The pubic symphysis and iliac crests are reliable landmarks regardless of maternal body habitus [40]. In contrast, the location of soft tissue landmarks may be atypical. In patients with an apron-like panniculus, the umbilicus is a poor landmark for identifying the underlying location of pelvic organs because it is displaced caudally from its normal location at approximately the level of the iliac crest. As a result, the umbilicus may be caudal to the lower uterine segment, and care must be taken to not make an incision that may go through to the other side of the pannus instead of into the abdominal cavity.
●Transverse or vertical? – The choice of incision should be based on the surgeon's judgment regarding patient specific technical factors (eg, type of pannus/where the weight is concentrated). Whether a transverse or vertical incision is superior for the pregnant patient with obesity remains controversial, as no randomized trials have shown a clear benefit to one versus the other in these patients [41]. Some retrospective studies have reported higher wound complication rates in patients with vertical incisions than in those who underwent a transverse incision (wound infection: vertical incision 35 to 46 percent; transverse incision 9 to 21 percent) [42-44]. However, differences in risk factors for wound complications between patients undergoing one incision versus the other may have accounted for these findings. Others have not observed a difference in outcome by type of incision after controlling for confounders [13,45-47].
•Suprapubic low-transverse incision – The adipose tissue two finger-breadths cephalad to the pubic symphysis is not particularly thick, even in patients with severe obesity. For patients who weigh less than approximately 400 pounds (181 kg), elevating the panniculus and retracting it cephalad with a panniculus retractor/retention system or tape as discussed above (see 'Logistics' above) allows placement of a low-transverse (eg, Pfannenstiel) or low-midline (vertical) incision [48]. This weight threshold is based on personal experience and other anecdotal evidence.
A disadvantage of making an incision under the panniculus is that the wound must heal in a warm, moist environment with higher bacterial colonization, thus potentially increasing the risk of infection.
•Supraumbilical incision
-Transverse – For patients who weigh over 400 pounds (181 kg), and particularly those over 600 pounds (272 kg), a transverse supraumbilical incision has some advantages: it has the strength of the transverse repair, avoids burying the wound under a large panniculus, and provides excellent abdominal exposure [12]. Permanent contraception (including salpingectomy), if desired, is easily achieved with this incision. However, it has not been proven to be less morbid than a Pfannenstiel incision [42,49] and the weight threshold is based on personal experience and other anecdotal evidence.
-Vertical – A vertical supraumbilical incision is another option, when the panniculus is displaced caudally [50]. With caudal displacement, the umbilicus cannot be used as a landmark for estimating the location of pelvic organs; the pubic symphysis and iliac crests must be used.
A disadvantage of supraumbilical incisions is that exposure to the lower uterine segment can be suboptimal, necessitating a vertical hysterotomy, which is made in the midportion of the uterus extending toward the fundus. Rarely, this may require extracting a vertex-presenting fetus as a breech. An alternative suprapannicular subumbilical incision technique that displaces the panniculus caudad has been described in a pilot series of 17 patients; the authors state that it preserves access to the lower uterine segment and a potential low-transverse hysterotomy [51]. Further investigation is required.
●Incision length – The term fetus is likely to be large so a longer incision than used in patients without obesity is especially important to facilitate delivery. The alternative of manually stretching the incision to facilitate fetal extraction would be difficult due to the thick abdominal wall.
●Technique – The risk of infection can be reduced by not making multiple shallow strokes by scalpel or electrosurgery (which increases tissue damage) and by avoiding excessive dissection of the subcutaneous tissues (which increases dead space).
Hysterotomy incision — We prefer a transverse incision in the lower uterine segment because it is associated with the lowest rate of uterine rupture in subsequent pregnancies. This is especially important for pregnant patients with obesity in whom rapid administration of anesthesia and cesarean birth may not be technically possible if the uterus ruptures in a future pregnancy. The risk of rupture in future pregnancy with a true low-vertical incision also appears to be low, but vertical incisions often extend into a portion of the thick upper uterus. Factors involved in choosing the type of hysterotomy are reviewed in more detail separately. (See "Cesarean birth: Surgical technique", section on 'Choice of incision' and "Uterine rupture: After previous cesarean birth".)
Fetal extraction — The fetus can be difficult to extract because of the location of the hysterotomy and/or the surgeon's or assistant's inability to provide adequate fundal pressure. Some options to facilitate extraction include extraction as a breech or use of one or two forceps blades or a vacuum device. (See "Cesarean birth: Management of the deeply impacted head and the floating head".)
Fascial closure
●Midline incision – Mass closure of vertical incisions (figure 1) may reduce the risk of dehiscence and hernia formation compared with layered closure. A meta-analysis of randomized trials of patients undergoing laparotomy for a variety of indications demonstrated no clear benefit of mass closure, but interpretation was limited by multiple sources of bias and very heterogeneous patient populations (type and reason for of surgery, type of incision [eg, transverse, midline]) [52].
The classic Smead-Jones technique (far-far-near-near) or an alternative approach (far-near-near-far) are acceptable methods (figure 1) [53]. The key point is to approximate the fascia without strangulation. Continuous mass closure with nonabsorbable or slowly absorbable suture has proven safe and equally effective as interrupted techniques in randomized trials [54-56]. 0-polypropylene nonabsorbable suture or a delayed absorbable suture, such as looped 0-PDS or 1-PDS, is acceptable. The continuous suture incorporates a small amount of subcutaneous fat, the rectus muscle, the rectus sheaths, the transversalis fascia, and, optionally, the peritoneum. The total length of the suture should be approximately four times the length of the incision; a suture that is too short increases the risk of hernia formation [57]. Inverted knots keep knot stacks out of the subcutaneous tissues. (See "Principles of abdominal wall closure".)
●Transverse incision – Few randomized trials have evaluated the optimum closure technique for transverse fascial incisions. A continuous nonlocking closure with slowly absorbable #0 or 1 braided suture (eg, polyglactin 910) is a common approach, but a monofilament (eg, polydioxanone) can also be used [52,58]. (See "Cesarean birth: Surgical technique", section on 'Fascia'.)
Subcutaneous closure — The subcutaneous adipose layer should be closed when the layer is ≥2 cm thick; an absorbable 3-0 running suture is commonly used [59,60]. In a meta-analysis of randomized trials, suture closure of the subcutaneous adipose layer at cesarean birth decreased the risk of subsequent wound disruption by one-third in patients with subcutaneous tissue depth ≥2 cm (relative risk [RR] 0.66, 95% CI 0.48-0.91), but not in those <2 cm (RR 1.01, 95% CI 0.46-2.20) [60].
Drains — Subcutaneous drains are not recommended, as randomized trials show no clear benefit in the overall obstetric population (wound complications RR 0.85, 95% CI 0.55-1.32; wound infections RR 1.02, 95% CI 0.85-1.21) [61] or in patients with obesity who have a subcutaneous closure [43,62,63] or in the general surgical population [64]. In an observational study of patients with ≥4 cm of subcutaneous thickness at cesarean, the use of a drain was associated with an increased risk of wound complications [65].
Skin closure — The authors have used subcuticular polypropylene (RPP) and absorbable sutures, both for infrapannicular and supraumbilical incisions. In three randomized trials evaluating skin closure techniques in patients with obesity, composite wound complication rates were generally similar for staple and subcuticular suture methods [66-68], similar to findings in the overall obstetric population. (See "Cesarean birth: Surgical technique", section on 'Skin closure'.)
POSTOPERATIVE MORBIDITY — Postpartum morbidities that are more common in patients with obesity after cesarean birth include wound dehiscence and infection [9], postpartum hemorrhage [69], thromboembolism [70,71], and pulmonary morbidity (particularly in patients with obstructive sleep apnea [OSA] or obesity hypoventilation syndrome [OHS]) [72]. These risks are discussed in detail separately. (See "Obesity in pregnancy: Complications and maternal management", section on 'Postpartum'.)
POSTOPERATIVE CARE
General measures
●Close monitoring – Patients with obesity require close postoperative monitoring until recovery of respiratory function. For those with a history of cardiac arrhythmias or coronary artery disease and/or chronic obstructive pulmonary disease (COPD), sleep apnea, and/or asthma, admission to a unit that can provide continuous cardiopulmonary monitoring for as long as it is needed, generally 24 hours, is advised. In addition to routine assessment of vital signs, use of continuous pulse oximetry and capnography (where available) can detect impaired oxygenation and ventilation, respectively. Fluid intake and output should be monitored closely to maintain euvolemia, especially in patients with cardiopulmonary disease. (See "Hospital accreditation, accommodations, and staffing for care of the bariatric surgical patient", section on 'Monitoring and safety devices'.)
All patients should undergo regular assessment of their level of sedation and respiratory function during wakefulness and sleep. Guidance for monitoring for respiratory depression after cesarean birth is described separately. (See "Post-cesarean delivery analgesia", section on 'Side effects and complications'.)
Respiratory depression (eg, respiratory rate <8 to 10 breaths per minute, hypoxemia [oxygen saturation ≤95 percent], hypercapnia), sedation, poor respiratory effort or quality, snoring/noisy respiration, or desaturation are indications to rouse the patient immediately and instruct them to take deep breaths [73]. More invasive monitoring (eg, pulse oximetry and capnography) may then be required.
●Positioning – Both a head-up, 30-degree position and lateral decubitus positioning minimize compromise to airway and respiratory function. A Troop elevation pillow may assist in head elevation.
If the patient develops vaginal bleeding and needs to undergo a speculum examination, the lithotomy and Trendelenburg positions can reduce ventilation by decreasing lung volume and increasing the work of breathing, but do increase venous return and cardiac output. Therefore, patients should be appropriately monitored during such examinations.
●Respiratory physiotherapy – Respiratory physiotherapy, including incentive spirometry, can be helpful to reduce atelectasis. Noninvasive continuous positive airway pressure is useful for patients preoperatively identified to have OHS or OSA. (See "Strategies to reduce postoperative pulmonary complications in adults" and "Noninvasive positive airway pressure therapy for the obesity hypoventilation syndrome" and "Anesthesia for the patient with obesity", section on 'Post-anesthesia care unit management'.)
●Early ambulation – Early ambulation may improve bowel function, as well as decrease the risk of venous thrombosis. Physical therapy may be helpful for patients with mobility limitations. As noted above, thromboprophylaxis is appropriate at least until the patient is fully ambulatory. (See 'Prevention of venous thromboembolism' above.)
Pain management — Specific approaches for postcesarean multimodal analgesia are described in detail separately. An example of a protocol for postcesarean pain management in hospitalized patients is shown in the table (table 2). (See "Post-cesarean delivery analgesia".)
Multimodal, opioid-sparing analgesia relies on various treatment modalities utilizing multiple analgesics with different mechanisms of action and side effects. Using multimodal analgesia seems to be the best approach to provide pain relief adequate to support ambulation, allow the patient to be alert and energetic to care for the newborn, minimize drug transfer into breast milk, and minimize side effects in both the mother and newborn. Avoidance of unnecessary opioid exposure is important in all patients to minimize risk for opioid use disorder.
In patients with a history of OSA or obesity hypoventilation syndrome (OHS), opioid-related respiratory depression is an additional concern. Management of these patients is reviewed separately. (See "Postoperative management of adults with obstructive sleep apnea".)
Wound care
General care — If the incision is under the panniculus, placing clean rolled towels beneath the panniculus postoperatively or an adhesive panniculus retractor improves air circulation. Choice of dressing is reviewed separately. (See "Principles of abdominal wall closure", section on 'Dressings'.)
Incisions should be closely monitored for signs of infection or disruption, even after the patient leaves the hospital [43,74]. In one series of 194 patients with BMI ≥50 kg/m2 who underwent cesarean birth, 30 percent had a wound complication: 90 percent were wound disruptions and 86 percent were diagnosed after the patient was discharged from the hospital [43].
The patient (or a household member) should check the incision daily for increasing erythema or tenderness, drainage, or separation. This assessment can be complemented by a wound check by a health care provider two to three days after discharge and again at the time of suture removal. Telemedicine, including use of a smartphone application, can be convenient and helpful for monitoring wound healing [75]. An optimum post-discharge surveillance method has not been established [76].
Negative pressure wound therapy — We do not use negative pressure wound therapy as part of postoperative wound care on our service as the overall value of the intervention in patients with obesity undergoing cesarean birth remains unproven. Negative pressure wound therapy may reduce surgical site infection (SSI), but experience with clean, closed surgical wounds is limited and, among patients with severe obesity, there are few reports of its use in postcesarean birth according to abdominal skin incision type.
In a meta-analysis of prophylactic negative pressure wound therapy versus standard care after cesarean birth in patients with obesity (9 trials, 5529 participants), the intervention reduced the risk of SSI compared with standard wound dressing (1.7 versus 8.3 percent; relative risk [RR] 0.79, 95% CI 0.65-0.95) [77]. However, it did not reduce the rate of other wound complications (eg, dehiscence, seroma, bleeding), readmission, or reoperation, and it increased skin blistering. Limitations of the trials included practice variations in surgical care (eg, skin antisepsis, incision type, skin closure technique, prophylactic antibiotic timing and dose), inconsistent definitions regarding diagnosis and outcome, lack of blinding and subjective judgment of some outcomes, and industry sponsorship of some trials.
Further analysis and rigorous research are needed before prophylactic negative pressure wound therapy can be routinely recommended for patients with obesity undergoing cesarean birth, given the limitations of available data. Future trials should utilize best practices for reducing SSIs and stratify randomization by risk (eg, scheduled versus unscheduled cesarean birth). (See "Negative pressure wound therapy".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cesarean birth".)
SUMMARY AND RECOMMENDATIONS
●Risk assessment – Patients with obesity (table 3) often have risk factors that increase their morbidity from cesarean birth, including comorbidities (table 1), logistical challenges (eg, operating tables and equipment, intravenous [IV] and epidural catheter placement), increased blood loss, and altered pharmacodynamics. (See 'Factors to consider during surgical planning' above.)
●Risk mitigation – Key interventions to reduce risk include:
•Preparation – Preparation includes preoperative patient assessment for risk factors for complications; use of aspiration, thromboembolism, and infection prophylaxis; and availability and use of appropriate equipment. (See 'Preoperative evaluation and testing' above and 'Preoperative interventions to reduce the risk of complications' above and 'Logistics' above.)
•Antibiotic prophylaxis – Antibiotic prophylaxis is based on the patient's weight and risk status (planned versus intrapartum cesarean) (See 'Prevention of surgical-site infection' above.)
All patients (assuming no allergy):
-≥120 kg: cefazolin 3 g IV within the 60 minutes prior to surgical incision
-<120 kg: cefazolin 2 g IV within the 60 minutes prior to surgical incision
Patients with labor and/or rupture of membranes:
-Add azithromycin 500 mg IV
Patients with a history of true penicillin allergy (immediate hypersensitivity reaction):
-IV clindamycin 900 mg plus gentamicin 5 mg/kg based on dosing weight
•Thromboprophylaxis – We apply an intermittent pneumatic compression device sized to accommodate large legs preoperatively, and add pharmacologic thromboprophylaxis postpartum once the patient is deemed stable from a surgical/anesthesia standpoint. Choice of drug (unfractionated versus low molecular weight heparin), timing of administration, dosing, and duration of thromboprophylaxis (during hospitalization only versus for six weeks) are reviewed separately. (See "Cesarean birth: Preoperative planning and patient preparation", section on 'Thromboembolism prophylaxis'.)
●Anesthesia – As with patients without obesity, regional anesthesia is preferred in most patients because it is typically safer than general anesthesia; however, the choice between general and regional anesthesia should be guided by the urgency of the case, requirements of the surgical procedure, and comorbidities. (See 'Anesthesia' above.)
●Procedure
•Landmarks – Abdominal soft tissue landmarks are often distorted in patients with obesity. The umbilicus is often anatomically directly over or caudal to the lower uterine segment because the large panniculus draws it caudally, whereas the position of the symphysis pubis and iliac crests are reliable. (See 'Abdominal wall incision' above.)
•Abdominal incision – For patients weighing less than 400 pounds (181 kg), we make a Pfannenstiel incision if the panniculus can be adequately retracted cephalad. For patients weighing 400 pounds (181 kg) pounds or more, we make a transverse or vertical supraumbilical incision with the panniculus displaced caudally. This weight threshold is based on personal experience and other anecdotal evidence. (See 'Abdominal wall incision' above.)
•Hysterotomy incision – When possible, we make a low-transverse rather than a low-vertical incision since the latter may extend into the upper uterine segment, increasing the risk of uterine rupture in subsequent pregnancies. (See 'Hysterotomy incision' above and "Cesarean birth: Surgical technique", section on 'Choice of incision'.)
•Abdominal closure
-In patients with a midline fascial incision, we suggest a Smead-Jones or comparable interrupted technique or mass continuous closure with nonabsorbable or slowly absorbable suture (figure 1) rather than a layered closure (Grade 2C). We believe this is especially important for supraumbilical incisions. Both approaches are equally effective for reducing the risk of dehiscence or hernia formation.
In patients with a transverse fascial incision, a continuous nonlocking closure with slowly absorbable #0 or 1 braided suture (eg, polyglactin 910) is a common approach, but a monofilament (eg, polydioxanone) can also be used. (See 'Fascial closure' above.)
-We recommend closure of subcutaneous tissue ≥2 cm thick (Grade 1B) and we suggest not placing a subcutaneous drain (Grade 2C). (See 'Subcutaneous closure' above and 'Drains' above.)
●Postpartum morbidity – Postoperative morbidities that are more common in patients with obesity after cesarean birth include wound dehiscence and infection, postpartum hemorrhage, thromboembolism, and pulmonary morbidity (particularly in patients with obstructive sleep apnea [OSA] or obesity hypoventilation syndrome [OHS]). (See "Obesity in pregnancy: Complications and maternal management", section on 'Postpartum'.)
●Postoperative care
•Monitoring – All patients should undergo regular assessment of their level of sedation and respiratory function during wakefulness and sleep. Respiratory depression (eg, respiratory rate <8 to 10 breaths per minute, hypoxemia [oxygen saturation ≤95 percent], hypercapnia), sedation, poor respiratory effort or quality, snoring/noisy respiration, or desaturation are indications to rouse the patient immediately and instruct them to take deep breaths. More invasive monitoring (eg, pulse oximetry and capnography) or admission to a unit that can provide continuous cardiopulmonary monitoring may be required. (See 'General measures' above.)
•Pain management – As with patients without obesity, multimodal, opioid-sparing analgesia is used for all patients. An example of a protocol for postcesarean pain management in hospitalized patients is shown in the table (table 2). (See "Post-cesarean delivery analgesia".)
•Wound management – If the incision is under the panniculus, placing clean rolled towels beneath the panniculus postoperatively or an adhesive panniculus retractor improves air circulation. Incisions are closely monitored for signs of infection or disruption, which are more common in patients with obesity. Routine prophylactic negative pressure wound therapy is not required. (See 'Negative pressure wound therapy' above.)
